Transcript Slide 1

National Academy for State
Health Policy
Reforming State Long-Term
Services and Supports through
Participant Direction
Texas: Selfdetermination with
Consumer
Directed Services
Marc S. Gold
Texas Department of Aging and Disability Services
October 5, 2010
Consumer Directed Services (CDS) History
 1997: House Bill 2084: pilot model of
participant direction
 1999: Senate Bill 1586; expand CDS option
to Medicaid programs and established a
CDS stakeholder workgroup
 2001: CDS added to the Medicaid waivers
 2004: Consolidation of Human Services
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 2010: CDS option in all waivers, state plan
and managed care programs
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Long Term Services & Supports Program
 Waivers:
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 Older and Physical Disabilities
 Community-based Alternatives
 Medically Dependent Children Program
 STAR+ (managed care)
 Intellectual and Developmental Disabilities
 Home and Community-based Services
 Deaf-Blind Multiple Disabilities
 Community Living Assistance and Support
Services
 Texas Home Living
 State Plan Programs: Attendant Services
 Primary Home Care
 Community Attendant Services
 (b) attendant services
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What is Texas CDS?
 Not “cash and counseling”
 Mechanism to control hiring of selected
direct service workers and licensed staff
 Service budget determined by agency staff
 Limited budget flexibility: determine pay
rate within service rate set by state
Texas CDS is not:
 Cash option
 Service provision by legally liable adults
(spouse/parent)
 “Individual goods and services”
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Texas 2010
 All individuals, across disabilities
and regardless of age have the option
to use CDS
 Statutory Authority
 1915 (c) waivers
 1915 (b) waivers (managed care)
 1915 (j) state plan amendment (DRA
2005) TX: attendant programs
 No screening tool: self-determination
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Available Services through CDS
 All programs: Personal assistance
services; habilitation and respite
 Selected waivers: Nursing and
physical/occupational/speech therapies
 Texas Home Living: All services
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Support Services to CDS Model
 Financial Management Services (FMS)
 payroll, deposit taxes and file tax
reports
 $202/month in waiver program
 $110/month in attendant programs
 Support Consultation
 Assistance and training: coaching the
individual how to interview/hire
 $15.37/hour (from overall budget)
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Getting the Word Out
 Case managers or service coordinators
provide information about the CDS option
at program enrollment and annually upon
service review
 Information includes an overview of the
CDS option, employer responsibilities, FMS
provider responsibilities as well as
benefits and risks of using the CDS option
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Individual Responsibilities
 Serve as employer
 Recruit and hire services provider
 Determine the work schedule
 Determine the wage rates and benefits
 Provide initial and ongoing training
 Approve services provider timesheets
 Handle conflicts
 If necessary, terminate provider
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Budget and Spending Flexibility
 Budget based on approved service plan
 Any budget change must be proceeded by a
service plan change
 Wages determined within the rate established by
the state
 Budget allows employers to purchase employerrelated supports: advertising costs, fax machine
for sending time sheets, background checks and
training for attendants (not individual
goods/services)
 90% of budget must be allocated to service
provider pay and benefits
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Utilization: 2008-2010
Total Number of CDS Users In Texas by Quarter
7,000
6,000
5,000
4,000
3,000
2,000
1,000
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Factors in Increase Usage
 Addition of CDS to waiver program (HCS;
MDCP)
 Expansion of managed care to urban areas
within Texas
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Population Differences
 49% of participants with related conditions
in CLASS waiver program
 3% of participants with intellectual or
developmental disabilities in HCS waiver
 Less than 1% participants with physical
disabilities and those who are aging in CBA
 33% of parents of children with special
medical needs MDCP waiver program
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Fee-for-Services vs. Managed
Care
 Less than 1 percent in fee-for-service programs
for individuals who are older or with
physical disabilities
 Three percent for same population in
managed care
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Factors Impacting Usage
 Elderly too ill to manage self-direction
 Lack of informal support to help with selfdirection
 Independent case managers versus agency
case managers
 Conflict of interest when case management
provided by program provider
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Quality Assurance/Improvement
 Data collected from the:
 Personal Experience Survey
 National Core Indicators
 Those who use CDS reported they:
 required less medical attention
 required less support to prevent
disruptive behavior
 felt safer in their homes
 were more satisfied with their lives
 felt less lonely
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Cost Effectiveness Studies
 4 studies, however mixed results with
inconclusive data
 Trend data indicate:
 Utilization of services increased with
CDS
 Few hospitalizations and return to
nursing facility
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Strengths/Considerations
 Strengths
 Available to all individuals served by
Texas’ long-term services system
 Operates under a single set of
administrative rules; consistency
 Considerations
 Ties CDS to specific waiver and rule
requirements such as service plan
developments/provider requirements,
case management or service coordination
 Limits budget flexibility
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Workgroup Recommendations
 Develop and implement outreach activities
across TX to increase awareness and
understanding of the benefits of the CDS
 Establish a certification process for CDS
Agencies (CDSAs) to improve quality of
services and ensure cost-effective oversight
 Make workers’ compensation insurance
affordable for workers
 Create a budget neutral, cross disability, selfdetermination pilot waiver in at least one rural
and one urban site
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Future Considerations
 Service Responsibility Option
 Self-determination Waiver
 Addition of individual goods and services
 Require certification
 Regional “supra” contract role
 Increase responsibilities of support advisors
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Contact Information
Marc S. Gold
Director, Promoting Independence
Initiative
512.438.2260
[email protected]
www.dads.state.tx.us/business/pi/inde
x.html
Elizabeth Jones, Ph.D., CDS Specialist
512.438.4855
[email protected]
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Websites
 CDS Option:
http://www.dads.state.tx.us/providers/CDS/
index.cfm
 TX Administrative Code: Title 40, Part 1,
Chapter 41:
http://www.dads.state.tx.us/providers.CDS/
Ch41CDSJan2009.pdf.
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